39D0202602 CLIA NUMBER - IMMACULATE MARY HOME

Laboratory Demographics

  • CLIA Code: 39D0202602
  • Facility Name: IMMACULATE MARY HOME
  • Facility Address: 2990 HOLME AVENUE
    PHILADELPHIA, PA
    ZIP 19136
  • Facility Phone: 215 992-1824
  • Facility Type: Skilled Nursing Facility/Nursing Facility
  • Facility Type: Waiver
  • Lab Director: DR. BRIAN B. KIMMEL
  • NPI Number: 1780751115
  • Taxonomy: 332BP3500X - Durable Medical Equipment & Medical Supplies

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CLIA Record

Field Name Field Value
CLIA Number 39D0202602
LAB Type Skilled Nursing Facility/Nursing Facility
Facility Name IMMACULATE MARY HOME
Street 2990 HOLME AVENUE
City PHILADELPHIA
State PA
ZIP 19136
Phone 215 992-1824
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 9/1/2024
Certificate Expiration Date 8/31/2026
Facility Type Skilled Nursing Facility/Nursing Facility
Lab Director DR. BRIAN B. KIMMEL

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This page was last updated on: 9/29/2025